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Click ‘Get Form’ to open the humana referral authorization form in the editor.
Begin by entering the Sponsor SSN, followed by the Patient Name, Date of Birth (DOB), and Zip Code. Ensure all personal information is accurate for proper processing.
Fill in the Address, City, State, and Phone number of the patient. If applicable, indicate if there is Other Health Insurance by selecting 'Yes' or 'No' and provide the Carrier name and Policy number if 'Yes' is selected.
Select the Provider or Setting type from options such as Physician's Office or Outpatient Facility. Specify the Date of Service and Point of Contact details if known.
Indicate the Type of Service required by checking appropriate boxes like Office Visit or Surgical/Diagnostic Procedure. Provide any necessary diagnosis codes for inpatient admissions.
In the Presenting symptoms section, describe the reason for referral along with any pertinent history or special situations that may assist in processing.

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2018	4.9 Satisfied (36 Votes)
2010	4.8 Satisfied (48 Votes)

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